Healthcare Provider Details

I. General information

NPI: 1447480470
Provider Name (Legal Business Name): BENNY M NINAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2009
Last Update Date: 07/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6327 43 TORRESDALE AVE
PHILADELPHIA PA
19135
US

IV. Provider business mailing address

9992 GARDENIA LN
PHILADELPHIA PA
19115-1100
US

V. Phone/Fax

Practice location:
  • Phone: 215-331-9929
  • Fax:
Mailing address:
  • Phone: 215-856-3336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP045841L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: